September 2016
Newsletter

Dear Friends,

Every day we try to convince ourselves that we are doing the right thing, to the best of our efforts, and that our hard work and commitment will bear fruit, sooner or later. This gives us the strength to keep going, day after day, in the face of adversity. And every once in a while, we come across news that makes us buckle before its intensity, and brings home to us the truth that we still have a long, long way to go.

On the 14th of August 2016, a leading newspaper in India published an article about a man who moved a local court in the Chittoor district of Andhra Pradesh, seeking to euthanize his 4-year-old son. He was denied this request.

According to the article, the little boy, Mahesh, was diagnosed with cancer a few weeks after he was born. The family took him to some of the major cities of southern India – Chennai, Hyderabad, Vellore and Bangalore – seeking help and treatment. They racked up a debt of 15,00,000 rupees (the equivalent of approximately $22,500) – a prohibitive amount for anybody in a developing country. A devastating amount for a family whose only breadwinner works as a barber in a village.

Each of these cities has established pain and palliative care centers. Yet, no referrals were made to them. Mahesh suffered unnecessary, debilitating pain. He cried constantly, causing his family unrelenting anguish. At the end of 4 years, the family had sold everything they owned, with no resulting benefit to the child.

On reading this article, palliative care teams in both Hyderabad and Trivandrum started frantically networking in a desperate attempt to track down the family, reach them and try to alleviate Mahesh’s suffering before it was too late. It took the teams close to 48 hours to finally make contact with the father. The family was found in Bangalore, with little Mahesh in an ICU, bleeding from multiple places.

His pain had still not been addressed.

A counselor from the MNJ Institute of Oncology, Department of Pain and Palliative Care made an overnight bus journey carrying essential opioids to try and reach the family, while other avenues were explored locally.

On the 20th of August, despite our best efforts, Mahesh died hooked up to machines, far from home, in unyielding and unspeakable pain, watched by his horrified parents.

He had completed his 5th birthday just the day before.

This is not a story about the pros and cons of euthanasia – a concept hotly debated today by an entire country that, at best, has a feeble grasp on its many nuances. This is a story about the unforgivable failure on the part of the healthcare system to address the boy’s pain in the absence of curative treatment options.

Before we demand unilateral legislation for or against euthanasia, we need to examine the reason why so many people seek it. If the sole reason is pain and distress that we have an arsenal of medication to significantly relieve, but withhold, it is not just incompetence or ignorance – it is the equivalent of willfully inflicting torture on another human being.

The ordeal left deep scars on everyone who connected with this family for the few days and hours before Mahesh died. A senior palliative care physician reported feeling “ashamed” that one of the hospitals Mahesh was taken to is a stone’s throw away from her office window. The hospital did not even think to refer the child to its neighbour, which happens to be one of the leading Palliative care departments in the country.

The counselor who made the overnight journey, and has extensive experience in palliative care, was left numb with grief and despair in the aftermath of witnessing Mahesh’s traumatic death.

The rest of us continue to feel in turn appalled, angry, indignant, helpless and heartbroken at the reprehensible way in which this family has been dealt with over five long years, when all the while help was at hand.

Mahesh’s father said that on several occasions, after making what must have been a cruel journey over long distances with a very sick child and no resources, they were outright denied admission.

We cannot take lightly the fact that we know about Mahesh only because someone told his story, whatever the angle might have been. There are thousands of families undergoing this ordeal as you read this. Some have not waited for death to come naturally. Two years ago, a couple killed their own child and then committed suicidewhile admitted in a hospital. How many more must be taking their lives into their own hands hidden behind the veil of impoverished obscurity, and going unnoticed?

At what point will we finally tap into the resources and teams that are waiting on standby for just that one referral a hospital has to make when they are no longer equipped or inclined to manage pain?

There are situations over which we have no control as a society. And then there are situations that can be made better. If you care about the euthanasia debate, you need to begin with the back-story.

If you are reading this, you have access to us.

Through us, you have access to organizations that are working hard to improve access to pain management in India, and

You can help put an end to such incidents that can only be classified as atrocities.

1-2-3 steps. Not even six degrees of separation.

Don’t turn away from this story because you don’t think you are like that poor family or that your life is not connected with theirs; or that you can get to the best hospitals. The best hospitals in this country would usually offer high-tech, expensive, painful intensive care to the dying person; but not pain relief. Less than 1% of hospitals in our country have oral morphine, which is classed as an essential medicine in the Government of India’s list.

If you consider one of the markers of a civilized society to be its stand on the right to self-determination, know that making available the human right to freedom from pain is an even bigger touchstone.

Everyone is connected. We are your connection. You can play a part.

Let no more people seek to euthanize themselves, their children or loved ones when a pain-free life is within reach.

In June 2016, the Government of India uploaded on its website a proposal for a draft law for “Protection of Terminally ill Patients and Medical Practitioners”.

The way it was drafted, it threatens to violate one’s autonomy and to worsen suffering towards the end of one’s life. Pallium India participated in two very successful public awareness programs on the subject, one in Delhi and one in Mumbai. Dr Nandini Vallath represented Trivandrum Institute of Palliative Sciences on both occasions.

Thank you, Sri M G Radhakrishnan of Asianet News for moderating the discussions, Dr B. Ekbal, member of the planning board of Kerala for inaugurating the event, and Dr Usha S. Nair, Smt Parvathy Devi and Justice Hariharan Nair for participating in the program. Thank you, supporters of Pallium India for joining. We are in a way pleased that the hall was overflowing beyond capacity, and apologise to the few people who could not find sitting room.

The department of palliative medicine at Kidwai Institute of Oncology has also been sanctioned new positions of Associate Professor, Assistant Professor and Senior Resident, so that they are now ready to start MD course in Palliative Medicine. The inspection by Medical Council of India happened on 20th August 2016.

Congratulations, Dr Linge Gowda and team!

A group of international palliative care experts were among those invited to advise on the revision of the WHO Guidelines on the Management of Cancer Pain in Adults at WHO Headquarters in Geneva from 28-29 July this year. The most recent version of WHO’s Cancer Pain Guidelines was published in 1996.

Civil Society organisations were invited to attend as observers of the process. These included: The International Association for Hospice and Palliative Care, Médécins Sans Frontiéres, the Pain and Policy Studies Group at the University of Wisconsin, Physicians for Responsible Opioid Prescribing, the Union for International Cancer Control, and the Worldwide Hospice Palliative Care Alliance (WHPCA).

This is the first effort, following the passage of the WHA resolution 67.19 on palliative care in 2014, to develop new global policy on symptom management. WHO Guidelines on the Pharmacological Treatment of Persisting Pain in Children with Medical Illnesses were published in 2012.

Close to 500 registrants from more than 35 countries participated in a three-day conference of the African Palliative Care Association (APCA) at Kampala, Uganda, on 17-19 August, 2016, jointly hosted by them and the Worldwide Hospice Palliative Care Alliance (WHPCA).

India has a lot to learn from Uganda and from Africa as a whole. In the face of poverty very often worse than in India, they have managed to achieve a great deal by the strength of team work and tenacity of purpose. How can one not admire the pioneering spirit of the Nobel Prize nominee, Dr Anne Merriman, who adopted the country first and then embraced Africa. Hundreds of enthusiasts, with “fire in the belly” as Anne would put it, lighted the candle from her – and look where they have reached! Certainly nowhere near excellent coverage of the continent or even of the country, but certainly they are moving forward at a steady pace.

The choir raised their voices and sang, “let us raise our candles and light up the sky!”

An enviable feature of the conference was a pre-conference workshop for a whole day on 16th August for ministers and their representatives from African countries. Imagine! Ministers sitting together and reviewing palliative care activities and progress including action on the World Health Assembly resolution of 2014 and on the sustainable development goals! The Prime Minister of Uganda himself attended the event. Not just to inaugurate; but to stay and take part in the deliberations.

An important side event at the APCA conference was the launch of the Anne Merriman Hospice foundation on 17th of August 2016 – an invigorating experience chaired by Dr Emmanuel Luyirika, executive director of APCA.

In her inspiring address, Dr Anne Merriman recounted the story of a dying girl who wanted pain relief and Coca-Cola. A nurse provided morphine and Coca-Cola. To Anne, that is the Essence of palliative care.

I am taking home a pearl from Dr Anne Merriman’s address, quoting Bishop Desmond Tutu: “You cannot be human all by yourself”.

A two-day meeting on “Scaling up Palliative Care Initiatives under National Health Mission: A National Consultation” was held on 11th and 12th August 2016 at National Institute of Health and Family Welfare (MoHFW), New Delhi. MoHFW officials including Prof Jagdish Prasad, DGHS, Dr. Alok Mathur, Mr.Satyanarayan Dash, and Dr Fukru Tullu, team leader, NCD, WHO Country office for India attended the program. Dr Nandini Vallath represented the WHO Collaborating Centre at TIPS.

The National Program for Palliative Care (NPPC) is now operational since 2012; however budget allocation has not been made and funds are now available for states directly from the NCD flexipool. Programme implementation plan (PIP) for palliative care needs to be submitted by the states. Model PIP is available on the website of the Directorate General of Health Services.

Palliative Care still lacks clarity despite being in practice in India for two decades. The group emphasized the need to include all diseases and not just cancer under the purview of palliative care.

A detailed action plan was drawn up for each state and the person(s) responsible for this identified.

“This is the era of evidence-based medicine. Coming together of the cancer centres in India is a great step and the tremendous possibility of pooled resources for impacting the quality of cancer care is way beyond anything possible through individual or institutional efforts.”

These words of appreciation were spoken by Dr Soumya Swaminathan, the director of the highest academic office in India, ICMR, on the occasion of the 6th meeting of the National Cancer Grid (NCG) held at Tata Memorial Hospital on the 9th and 10th of Aug 2016.

NCG is a growing network of cancer centres in the country, with 86 institutional members currently, that aims to reduce the disparities in the standards of patient care amongst various geographic regions of India. This is attempted through development of implementable evidence-based management guidelines for common cancers. These include a systematic method of data capture of every patient being treated at a cancer center. The clinical guidelines of NCG serves the dual purpose of assessing patterns of presentation (including common cancers, stages of presentation, etc.) and needs assessment of individual centers.

Exchange of expertise and mentoring between the centers and collaborative research are other prime objectives. National Cancer Library under the NCG provides open access to ample scientific literature for all the registered individual and institutional members to encourage and support high quality clinical and research practices. Medium and long-term steps include a voluntary process of audit and peer review[1].

Dr Soumya Swaminathan, who inaugurated the NCG website, emphasized the responsibility of keeping data on public domain and looked forward to the coming together of cancer registry and the ICMR Registry.

The uniqueness of this year’s meeting was its emphasis on developing palliative care services across the centres of the NCG network. A breakout session that included experts in the field as well as oncologists with interest, discussed and presented the strategies towards achieving this objective. Dr Mary Ann presented a hub and spoke model of extending the expertise after an initial ‘gap analysis’ across the centres. A direct possibility to incorporate palliative care components within the clinical and research guidelines developed by the NCG was also discussed.

We are especially happy to note these possibilities that NCG has opened for integrating the ‘care’ component within the comprehensive cancer management in India.

An entire session was devoted to inform practical IT based solutions for data access and technological support available for simplifications in the process of patient care.

There was a detailed presentation on Education for Community Health Outcome – the ECHO model for moving knowledge to where it matters; rather than moving patients to tertiary centres away from their base. It is a solution when knowledge is trapped in the heads of few who are practicing in major cities and urban centres beyond the access of most needy patients who are spread all over. ECHO appears to be a viable model for education in palliative care in the Indian scenario. Here experts from varied geographical locations organise case based discussions at regular intervals and impact capacity building.

We are grateful to Dr C. S. Pramesh and the entire organizing team of NCG, for making Trivandrum Institute of Palliative Sciences a member and feel strengthened and inspired by knowing that terrific leaders and visionaries are in positions that matter!

“I don’t know how to change the system; but what I learned during this workshop will reflect in my professional approach in caring for all my patients”, said a doctor who attended a two-day educational program on palliative care at KEM hospital, Mumbai on 15th and 16th July.

The program was organized by the department of Humanities of KEM hospital, in collaboration with Pallium India’s Trivandrum Institute of Palliative Sciences (TIPS), with the mission of its WHO Collaborating Centre to improve access to pain relief and palliative care. The program, which was primarily meant for undergraduate students, was attended by a large number of nurses and doctors, including post graduate students.

The enthusiasm of the attendees was palpable. As reflected by Dr Lopa Mehta’s comment, “Let us take this forward; this has to be integrated here in KEM hospital,” and in the Dean Dr Avinash Supe’s words, “I am interested in improving availability of essential narcotics in KEM hospital.”

The experience tells us again that a short two-hour sensitisation program may have its value, but we need to go in deeper depth if we are really to effect any change. Congratulations to Dr Nandini Vallath for initiating this activity and our thanks to all the faculty who contributed.

Dr Nandini reports that an important outcome from the meeting is that KEM, in its annual intercollegiate debate, has chosen the topic “The future of medicine does not lie in technology but in the humanities and enhanced clinical skills”.

Pallium India collaborated with Synod Hospital in Aizawl, Mizoram to start a palliative care service. This is Pallium India’s second project in Mizoram. Ten years ago, we had helped establish a palliative care unit in the Regional Cancer Centre in Aizawl, under the leadership of Dr Jeremy Pautu.

On the 30th of August, we helped conduct an opioid access workshop. Unlike the usual opioid access workshops that we do, here that part of the work was easy. The Drug Controller was very well-informed. There were no issues on that subject brought up during discussions, despite the background of a high incidence of addiction in Mizoram.

There was a very healthy discussion on involvement of voluntary organizations and on reaching out to the community, much of it led by Dr Jeremy Pautu, Dr Eric Zomawia of National Health Mission and Dr Sanghluna Renthlei.

We had a pleasant surprise. The health minister Lal Thanzara not only attended the meeting, but stayed on for an hour and a half. We have high hopes for Mizoram.

Thank you Dr Sanghluna for organising the event and for leading the palliative care program. Thank you Dr Lalchhanhima Ralte for connecting us with this institution in the first place and for reaching out into the community.

People with health issues (often we call them patients for want of a better term) must be on the forefront of health planning and advocacy. After all, health care is all about them, is it not?

The Indian Alliance of Patient Groups (IAPG), an umbrella body of 12 organizations, met up in New Delhi on 18 August 2016. Dr Geeta Joshi, palliative care physician and deputy director of the Regional Cancer Centre at Ahmedabad, represented Pallium India.

We thank Dr D S Ratna Devi, founding member of IAPG and Founder & CEO, DakshamA Health, for this important initiative.

Life can change in a moment … tomorrow, an accident or an illness could render you disabled, without the use of your arms or limbs.

Nothing in your imagination can prepare you for life after disability, when suddenly, you cannot independently do any of the things that you normally used to.

“We read about innumerable road accidents daily. But only the dead make the news. Have you ever thought how life would be afterwards for those people who survive these accidents with grievous injuries, who might have been crippled or bed-ridden for life?,” asks Ashla, a paraplegic and a volunteer with Pallium India.

Who better than Ashla would know about the isolation and despair of suddenly losing one’s mobility.
Life had come to a full stop for this young woman, an MCA holder, one fine day when she fell off a train. Her resilience and spirit and the helping hand of Pallium India’s chairman, M.R. Rajagopal, helped her find her feet again.

But for hundreds of others, who are left crippled for life, the lack of that helping hand and emotional support often proves to be their undoing

Untold misery

“Once they leave the hospital, everyone including doctors as well as friends and family, somehow assume that life will once again fall back into place. But few are able to accept their fate stoically and go through severe psychological stress and depression,” says Dr. Rajagopal.
Psychological issues aside, it is not easy to start life on a wheelchair one morning. One needs training to learn how to get into and out of the wheelchair independently, how to use the toilet, bathe and dress independently, to remove the urine bag etc. Early rehabilitation can do wonders to help these people.

Residential programme

The trauma that the spouse goes through is another untold tragedy. Pallium India decided to take up a rehabilitation scheme last year after they had to deal with some tragic situations wherein the spouses of some young paraplegic patients committed suicide.
With the Social Justice Department approving funding for the scheme, Pallium India today runs this residential rehabilitation programme at Arumana Hospital, Perunthanni, for the disabled, wherein, the patient and his/her family or care giver are given physical training, counselling and support so that the wheelchair-bound person can become independent once again.
Jeevathaalam

On Friday, the scheme was given a name — Jeevathaalam — and formally inaugurated by Social Justice Minister K.K. Shylaja.
The patient and spouse/family member can stay at the hospice for a month.
During this time, they undergo psychological and physical evaluation and receive training in daily living and counselling on issues – spiritual, sexual, diet guidance and physiotherapy. At a time, three patients can be accommodated.
So far some 18 patients with paraplegia have utilised this facility.

Sidhartha, a paraplegic shooter, was initially denied permission to participate in the National Games. But he persisted, and later was granted permission to compete in the prone category. And he has emerged as a state champion, rubbing shoulders with top professional shooters. Read the news in The New Indian Express: Beating severe odds to emerge champ

Ashla, herself a quadriplegic and a part-time software engineer, writes:
“Dear Sidhartha, You made my day. Of course the first thought was, Kudos, friend, very happy for you. What an achievement! You make me realise that it is true; sky is indeed the limit. Nothing can limit you unless you limit yourself. Keep inspiring!”

Dr N. Ajayan, a palliative care volunteer, drank deeply from the cup of suffering that he saw around him. From those life experiences comes this book of stories, titled “Anubhava Sakshyangal”. Dr Ajayan got the book published at his own expense, but the proceeds from its sale go towards serving the patients whom Pallium India cares for. The book that costs ₹100 is published by Kisalaya Publishers and is available at Pallium India office at Trivandrum. Please contact us if you are interested in purchasing this book.

Our friends from Australasian Palliative Link International (APLI) inform us that Dr David Brumley, a dear friend of palliative care in India, has been awarded a Medal in the General Division (OAM) in the Queen’s Birthday Honours List for 2016.

“The Queen’s Birthday Honours List recognises a diverse range of contributions and service across many fields, and highlights an individual’s significant achievements and service to the community.

David is a most worthy recipient of this award for his outstanding service to palliative care, not just here in Australia but to our friends in neighbouring countries. David was previously secretary of APLI. He has worked for many years teaching palliative care in Malaysia, Vietnam and Japan. He has been an outstanding mentor within Project Hamrahi, leading 4 teams to provide collegial support and teaching at the Cachar Cancer Hospital and Research Centre in Silchar, Assam.”

Congratulations, Dr David Brumley!

“We can’t stop treatment. We are supposed to do everything we can to keep the patient alive,” says the doctor about the man who has multiple organ failure, has “blood and urinary infection” and whose “kidneys are not functioning”.

The fight to prolong life at all costs continues. The wife and the daughter are allowed into the intensive care unit for five minutes each in the morning and evening. The daughter says, her 84-year old father, her best friend, was “wailing and roiling in pain, all I wanted to do was run, somewhere far, where his cries wouldn’t reach me.”

The man has many tubes inserted into his body. He cannot turn his head to the left because of the catheter going into his neck. He is in agony after every dialysis, in all “a harrowing experience.”

She stands by his side, “trying to convince all those who seemed to have a say on his life that it was a cruel line of treatment they were imposing.” The man got no sedatives or pain killers “for fear his weak heart could not take more chemicals.”

The daughter feels that the sight of him stripped of any sense of comfort or dignity on that hospital bed was unbearable. The doctor says the situation is bad. ‘‘If the situation is that bad, why can’t you get rid of all these wires and needles, and give him some sedative so he can sleep?’’ asked the daughter. But the doctor feels that he is supposed to do everything he can to keep the person alive.

“I didn’t get it,” writes the daughter. “Why keep the patient alive for a few more days, if it involved excruciating pain? Keep the patient alive for whose benefit?”

The saga continues. In hospital after hospital, all through India, patients are kept on life prolonging treatment even when they have no hope of recovery, because doctors feel they need to do everything to keep the person alive.

Doesn’t the problem lie right there? Is there clear understanding about what is the primary purpose of medical treatment? Is it to keep the heart beating at all costs?

In India, a new law is contemplated on end of life care. The original draft law published on the government’s website had made advanced directives invalid. We hope the draft is being corrected. There is a lot of discussion about euthanasia. While it goes on, no one talks about our right – yours and mine – to die a natural death, with some dignity when cure is not possible. The medical system doesn’t seem to know at all what its duty should be.

Isn’t it time we suspended the discussions on euthanasia and law, and go deep down into the basic issue – what is the duty of the medical profession? We need it there in golden letters, bold enough for every medical student and doctor to see that our duty is to cure when possible, relieve suffering and provide comfort, permitting dignity and recognising that death is the inevitable consequence of life, and that a natural death is NOT a failure of the medical profession.

Please read the article by Sindhu S, Pallium India’s volunteer, published in The Hindu: When Pain is Medicine

“During my morning rounds as I enquired about his pain, his eyes welled up with tears. As I asked gently, “Would you like to talk?” he started to cry, great heaving sobs filled with pent-up suffering.”

Dr Seema Rao, consulting psychiatrist from Mumbai, narrates this account of Sunder, a 38-year old driver who came to her hospice. He was suffering from penile cancer that had metastasized to the lymph nodes, lungs, and liver. “I don’t think you can do much for me. I have seen so many doctors, taken so many medicines, nothing helps. I want to die,” he said, his voice resonating with despair.

The narrative titled “Finding Peace Beyond the Pain” describes the journey of Sunder in the hospice. A caring husband and a doting father, he came to the hospice by force, in immense pain and suffering. He stayed on by choice and found the peace he was looking for, ably supported by the dedicated hospice team. He was able to live the last few months of his life as comfortably as was possible, and left this world in peace, with dignity. The narrative reiterates the belief that hospice, with its philosophy of active “total care” is an ideal place for addressing the concept of “total pain.”

The Journal of Pain and Palliative care Pharmacotherapy is an indexed journal that has made the narratives free access. The journal welcomes your Narratives on Pain, Suffering and Relief. Tell your story to the world and help improve palliative care awareness. If you have a story to narrate, share it with us. Write to info@palliumindia.org

One of the videos shown during a two-day workshop in KEM hospital was IAPC’s “Last Words”. One of the students who attended the program commented, “Anyone who is not moved to reflect on their practice differently after seeing the last words probably has a heart of stone.”

Indeed, the message that the Last Words video conveys is really powerful. Hats off to everyone who worked together to make this video possible.

Thiruvananthapuram: The health department has drawn up a plan to implement the pain and palliative care scheme in all district hospitals across the state. The proposal submitted by director of health services has been approved by the working group of the department. The scheme, which aims to promote a holistic approach to healthcare, will be implemented with the support of National Health Mission (NHM).

As per estimates, there are around 59 lakh people in the country who are in need palliative care but the required facilities reach only less than 2% of them.
The scheme envisages establishment of rehabilitation units at Kottayam, Kollam and Idukki district hospitals. District hospitals in Thiruvananthapuram, Malappuram, Ernakulam, Thrissur and Kozhikode would get Rs 2.5 lakh each for purchase of medicines and consumables and infrastructure development.

Special funds would be earmarked for hospitals in Palakkad, Kannur, Kollam, Alappuzha, Idukki, Kottayam, Wayanad and Pathanamthitta for improving their secondary palliative care units. Also, hearing aids would be provided to required persons. The five city corporations in the state would be handed over the funds to purchase medicine and equipment for palliative care units in urban areas.

The proposal also moots for incentives to palliative care promoters and honorarium for doctors and supporting staff. Meanwhile, it was decided that ‘Sayam Sandhya’ will be organized in all districts on October 1, as part of elderly care day observance. The programme includes seminars, gatherings, mass walk, health check ups, etc.

We welcome international visitors at Pallium India and appreciate the support from our colleagues around the world. We request that you contact us at least 2 weeks prior to your visit so that we can make the necessary arrangements. Sorry; we would discourage “drop-ins” for fear of the impact on patient care.

We have observership programs for interested professionals and students, collaborative visits, and long term placements. Click here for more information. Contact: visitors@palliumindia.org

PARTING SHOT

The boy, bit by a branded krait, treated in a government hospital at Birbhum needed ventilator support and was referred to a medical college hospital with facilities for it. He would need transportation with oxygen, the family was told, and so they organized an ambulance with oxygen.

But the ward nurses did not permit the oxygen cylinder to be carried during the transfer to the ambulance. The family in desperation, tried to rush him through the few hundred metres to the ambulance, but as the oxygen was removed, the child started gasping and died on the way.

Shocked? Don’t be. This kind of thing is not unusual. Did you read the story that we had presented to you written by Latha Srikanth – “A Tragedy of Errors”? Latha described another death from the combined cruelty of an insensitive medical system, misinformed, superstitious and misguided family members – all together being much more cruel than the snake.

Well, in the present case, read the response from the hospital as quoted by the Telegraph. The nursing superintendent of the hospital said “oxygen cylinders were not allowed to be taken out of the hospital ‘as a matter of policy’”. And the reason for the policy: “We have no one to bring the cylinders back”.

Hail policy!

Thank you for sharing this very moving and unfortunate story. I recently returned from a medical elective in Himanchal Pradesh and was very surprised about the lack of pain control utilized at the hospital. There seems to be a general misunderstanding about pain management, including the use of local anesthesia for invasive procedures. Thank you for your efforts.

Disclaimer: Information provided by Pallium India has been collected from different sources and though every effort has been made to ensure that it is up-to-date, its accuracy cannot be assured. Pallium India shall have no liability for any damages, loss, injury, or liability whatsoever suffered as a result of reliance on the information provided.